Avoid Payment Denial for Transitional Care

The Coding Expert Answers Your Questions

Editor's Note:Betsy Nicoletti, MS, a nationally recognized coding expert, will take your coding questions via email and provide guidance on how to code properly to maximize reimbursement. Have a question about coding? Send it here.

In this column, Nicoletti provides guidance on proper coding for transitional care management through commercial insurance and how to properly get paid for using telemedicine in advanced care planning.

Coding Transitional Care Management for Private Payers

Question: Do you know if I can bill a transitional care management (TCM) visit on commercial insurance like BCBS at my family practice?

Answer: TCM is a service provided to patients who are discharged from a facility (inpatient, observation, partial hospitalization, and skilled nursing) to a nonfacility setting, home, or independent living in an assisted living setting. It requires a phone call within 2 business days of discharge or documentation of two attempts to reach the patient, review of the discharge summary, medication reconciliation no later than the postdischarge evaluation and management (E/M) service, and non–face-to-face services provided by the physician, nurse practitioner, or physician assistant or a clinical staff member.

There are two CPT codes for TCM: 99495 and 99496. These are active CPT codes, covered by Medicare and most commercial insurances. A member of your staff can look up coverage by payer. Most payers have this information on their websites. For example, BCBS of Michigan describes coverage and the billing rules for TCM in an archived newsletter. You can read it here.

The non–face-to-face service provided in the 30-day postdischarge period may be additional education or support provided over the phone to the patient or caregiver, or coordination with community resources or other medical services. These non–face-to-face services can be performed anytime during the 30-day postdischarge period.

The payment also includes the first E/M service, typically an office visit. Use 99495 when the patient's condition is of moderate complexity and the E/M visit occurs within 14 calendar days of discharge. Use 99496 when the patient's condition is of high complexity and the visit occurs within 7 calendar days of discharge. If the patient's condition is of moderate complexity but is seen within 7 calendar days, use 99495.

Moderate and high complexity are defined in Medicare's Documentation Guidelines. For comparison, 99214 is defined as moderate-complexity medical decision-making and 99215 is defined as high-complexity medical decision-making.

Billing Advanced Care Planning via Telemedicine

Question: I provide advance care planning (ACP) services via telehealth as part of a palliative care service (CPT codes 99497 and 99498). Sometimes I provide this service with a family member because the patient is unable to participate due to dementia. Does the patient who is unable to participate (because of mental status) need to be on the video/phone call in order to be able to bill the ACP code?

Answer: Let's start with the Medicare rules for telehealth. The patient must be located in an underserved area, as defined by Medicare. The facility in which the patient is located receives a small payment for providing the equipment and location for the patient, and the facility bills healthcare common procedure coding system (HCPCS) code Q3014 (telehealth originating site facility fee). You can check if your patient is located in an underserved area here.

The physician or other healthcare professional must have two-way audio and video telecommunications with the patient. Telephone alone is not considered a telehealth service. The physician bills using a CPT or HCPCS code that is on the list of covered telehealth services. You can find that list here.

ACP is described as a service between a physician, physician assistant, or nurse practitioner as "face-to-face with the patient, family member(s), and/or surrogate." ACP codes 99497 (first 30 minutes; minimum of 16 minutes) and 99498 (add-on for additional 30 minutes) are on the telehealth list and so may be provided via two-way communication with a patient, family member, or surrogate who is in an underserved area. It is one of the rare services in which Medicare and other payers allow for billing when the beneficiary is not present, when that is medically reasonable.

Medicare has these specific and limiting rules about telehealth services. Unfortunately, medical practices need to check with other payers to see if they follow CMS rules or have their own rules for telehealth services.

Have a coding question? Send it in and it may be answered in a future column. (Please be sure to note your specialty in the text of the question.)

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Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.